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|
Attributes | |
ACN | 582870 |
Time | |
Date | 200305 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 582870 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : right oil press and quantity ind other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport flight crew : declared emergency |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : lighting performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
May/mon/03, I was assigned an evening check on aircraft X. I did the walk around and checked psi in tires and oil levels. On #2 engine, I stowed oil cap on top of tank instead of on top of servicing box. When I finished servicing the oil in #2 engine, I forgot to install the oil cap. I completed the service and mels, went home after shift end. I found out the aircraft had a maintenance turnback and had to make an emergency landing. I called to find out what had happened, and was told that the oil cap had fallen into throttle hinge. I believe that the change of the way I stowed the oil cap on #2 engine broke my routine, and that is why I forgot to install it.
Original NASA ASRS Text
Title: A B737-200 DECLARED AN EMER AND DIVERTED DUE TO LOSS OF RIGHT ENG OIL QUANTITY AND PRESSURE. ALSO EXPERIENCED R ENG JAMMED THROTTLES.
Narrative: MAY/MON/03, I WAS ASSIGNED AN EVENING CHK ON ACFT X. I DID THE WALK AROUND AND CHKED PSI IN TIRES AND OIL LEVELS. ON #2 ENG, I STOWED OIL CAP ON TOP OF TANK INSTEAD OF ON TOP OF SVCING BOX. WHEN I FINISHED SVCING THE OIL IN #2 ENG, I FORGOT TO INSTALL THE OIL CAP. I COMPLETED THE SVC AND MELS, WENT HOME AFTER SHIFT END. I FOUND OUT THE ACFT HAD A MAINT TURNBACK AND HAD TO MAKE AN EMER LNDG. I CALLED TO FIND OUT WHAT HAD HAPPENED, AND WAS TOLD THAT THE OIL CAP HAD FALLEN INTO THROTTLE HINGE. I BELIEVE THAT THE CHANGE OF THE WAY I STOWED THE OIL CAP ON #2 ENG BROKE MY ROUTINE, AND THAT IS WHY I FORGOT TO INSTALL IT.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.